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Prochlorperazine with or without diphenhydrAMINE

In the pediatric patient diagnosed with a refractory migraine, is prochlorperazine an effective treatment compared to ketorolac, metoclopramide, sodium valproate, IV magnesium?

Plain language summary from the office of evidence based practice: 
Based on low quality evidence, the Migraine in the ED CPG team conditionally recommends the use of prochlorperazine with or without diphenhydramine for the treatment of refractory migraine in the ED. The included studies are methodologically strong. However, the evidence is downgraded for inconsistency because definitions for (a) treatment success, (b) time to administer rescue medications, and (c) categorization of adverse events vary among the studies. Finally, the evidence is downgraded for imprecision, due to the small number of subjects with the desired outcome.

Literature supporting this recommendation: Eleven RCTs were used to support this recommendation. Prochlorperazine was compared to other medications (ketorolac, metoclopramide, magnesium sulfate, promethazine, and chlorpromazine) on the outcome, Treatment success one to two hours after treatment. (Brouseau, 2004, Coppola, 1995, Ginder, 2000. Callan, 2007, and Kanis 2013) (see Figure 2). For the comparison of prochlorperazine vs. metoclopramide, there was no difference in the change in pain intensity measured at 2 hours after medication administration. (Friedman, et al., 2008) When compared to magnesium sulfate, there was no difference between the treatment groups (Ginder, 2000). However, the sample sizes are exceedingly small (range 36-349 subjects). The included studies defined “treatment success” in various manners. Therefore, there is inconsistency among the studies.

Dose: Prochlorperazine 0.15 mG/kg (max 10 mG), administer via IV, 1 mG/min.

See Appendix B for the full Critically Appraised Topic (CAT).

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.